Personal Trainer Client Intake Form

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Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Height
cm/feet & inches
Weight
kg/stone
Phone Number

Area CodePhone Number
Email
example@example.com
Are you taking any medications? If yes, please list below.
Do you have any diagnosed/on going health problems?
Do you have any injuries? If yes, please list below.
How does your current diet look like?
What does a typical day of eating look like? Include estimate timings of meals/how many meals.
Do you take any supplements, if so what are they?
Do you smoke?
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
On average, how many hours sleep do you get on a daily?
How often would you like to have a personal trainer a week?
Which of the following statements fit in with your goals?

Other
When would you like to achieve these goals by?
Why is it do you think that you are struggling to achieve these goals? Lack of motivation? Lack of accountability? Struggling to train accordingly? Etc.
Appointment
Signature
Should be Empty:

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